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Risk Register BF July 06 by mifei

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									DRAFT BOARD REPORT                                                                                                                                           PCT RISK REGISTER
                                                                                                                                                                 JULY 2006




                                    Summary description of




                                                                                                                                                                                                                           implementing the plan?
                                                                                                                                                                                                                            Who is responsible for
                                                                                                               Likely impact to PCT




                                                                                                                                                                                                  Anticipated resource




                                                                                                                                                                                                                                                                                                                                               Is this the progress
                                                                                                                                                                                                                                                     Expected date of
                                                                                            Risk score (LxC)




                                                                                                                                                                Summary of risk




                                                                                                                                                                                                                                                                                                                          Progress report
                                                                             Consequences




                                                                                                                                                                                                                                                                                          Date of review
                                                                                                                                                                                                     implication (£)




                                                                                                                                                                                                                                                                        Residual Risk
  Risk Number




                                                                                                                                                                                                                                                                                                                                                   acceptable?
                                                                                                                                                                                                                                                       completion
                                                                Likelihood




                                                                                                                                                                  treatment
                                            risk
    1                                       2                     3             4               5                   6                                                 7                                   8                         9                    10             11               12                               13                        14

Objective 1 - Maintain Strategic Direction
    8           Fail to achieve recurrent financial               3             5           15                     E                  Minor surplus received in 2005/06. Board are                                       DF/ADofC                    Sep-06               E             Sep-06             Work continues on a countywide             Y
                balance                                                                                                               routinelly advised on progress through the reports                                                                                                                   basis and creating recurrent
                                                                                                                                      of the Directors of Finance and Commissioning                                                                                                                        balance is linked to service
                                                                                                                                                                                                                                                                                                           redesign

Objective 2 - Achieve all performance targets identified by the SHA and DoH as included within the LDP, including local targets
    9           Fail to achieve key targets                       4             4           16                     E                  Data analysis completed and issues have been taken                                   DPH                       Sep-06               E             Sep-06             Processes strengthened to                  Y
                                                                                                                                      forward across the county with some external support,                                                                                                                reduce emergency admissions
                                                                                                                                      with the aim of achieving certainty and an                                                                                                                           including pooling resources with
                                                                                                                                      understanding of financial risks. Work is ongoing with
                                                                                                                                                                                                                                                                                                           other Worcestershire PCTs
                                                                                                                                      the WAT on a countywide basis to investigate a variety
                                                                                                                                      of demand management schemes.
  10            Fail to implement PBC                             2             3               6               M                     The four criteria for universal coverage by December                                ADofC                      Dec-06               L             Sep-06             Strategy developed for universal           Y
                                                                                                                                      have now all been developed by the PCT. These are                                                                                                                    practice based commissioning
                                                                                                                                      specifically - budgets all issued to practices, monthly
                                                                                                                                      activity and spend details are provided to all practices,
                                                                                                                                      clinical governance issues have been addressed with
                                                                                                                                      provider accreditation process and practices have been
                                                                                                                                      made aware of the processes for offerring directed
                                                                                                                                      enhanced services.


  11            Staff do not have access to IT systems            3             3               9                 H                   Issues continue to be progressed with the Director of                                     FD                   Sep-06             M               Sep-06             Ongoing rapport with Director of           Y
                                                                                                                                      ICT Services at the WHAT and discussed with PCT                                                                                                                      IT at WAT
                                                                                                                                      NEDs' and at the May 06 PEC/Board Seminar.
  13            Non compliance with PEAT standards                3             3               9                 H                   Acceptable ratings have been provided for 2005/06 and                              DCS&N/FD                    Sep-06             M               Sep-06             Consideration is given to PEAT             Y
                                                                                                                                      funds identified within the capital programme. Specific                                                                                                              requirements within service
                                                                                                                                      plans to be agreed following a decision on future use of                                                                                                             reconfigurations
                                                                                                                                      Breedon ward.


Objective 3 - Maintain Financial Management
  18            Failure to achieve key financial targets in a     3             2              6                M                     Being taken through the PCT Reconfiguration Working                                 FD/DCS                     Sep-06             M               Sep-06                                                        Y
                planned way                                                                                                           Groups and collaborative working exists to develop
                                                                                                                                      robust countywide SLA's.




1 of 4                                                                                                                                                                                                                                                                                                                                        4/17/2010
DRAFT BOARD REPORT                                                                                                                                           PCT RISK REGISTER
                                                                                                                                                                 JULY 2006




                                     Summary description of




                                                                                                                                                                                                                           implementing the plan?
                                                                                                                                                                                                                            Who is responsible for
                                                                                                              Likely impact to PCT




                                                                                                                                                                                                   Anticipated resource




                                                                                                                                                                                                                                                                                                                                               Is this the progress
                                                                                                                                                                                                                                                     Expected date of
                                                                                           Risk score (LxC)




                                                                                                                                                               Summary of risk




                                                                                                                                                                                                                                                                                                                          Progress report
                                                                            Consequences




                                                                                                                                                                                                                                                                                          Date of review
                                                                                                                                                                                                      implication (£)




                                                                                                                                                                                                                                                                        Residual Risk
  Risk Number




                                                                                                                                                                                                                                                                                                                                                   acceptable?
                                                                                                                                                                                                                                                       completion
                                                               Likelihood




                                                                                                                                                                 treatment
                                             risk

Objective 4 - Maintain Operational Development and Delivery
    2           Documented management programme                  2             2              4                    L                 Environmental Policy developed, reviewed by H&S                                       DPH                       Sep-06               L             Sep-06                                                        Y
                                                                                                                                     Committee and to be agreed by the Clinical
                                                                                                                                     Governance Group, consitantly on a countywide basis
                                                                                                                                     for adoption by the successor PCT.

    3           Develop indicators                               2             2              4                    L                 Indicators to be developed following ratification of Policy                           DPH                       Dec-06               L             Sep-06                                                        Y

    6           Develop business continuity plans to             3             2              6                M                     Various BCPs now developed and a process for                                         DPH/DCS                    Sep-06               L             Sep-06             Current status report to be                Y
                ensure core systems can be retained in the                                                                           development of a full PCT BCP, in conjunction with                                                                                                                    included within an Annual Report
                event of system failure                                                                                              countywide PCTs continues through the Emergency                                                                                                                       to be provided to the September
                                                                                                                                     Planning Officer                                                                                                                                                      2006 PCT Board
  19            Emergency planning                               2             3              6                M                     The PCT has liaised with key partner agencies in all                                  DPH                       Sep-06             M               Sep-06             As above                                   Y
                                                                                                                                     aspects of emergency planning and a formal exercise
                                                                                                                                     programme had been completed. An Annual Report will
                                                                                                                                     be completed for 2005/06 and plans updated.




Objective 5 - Maintain local Service and Performance Agreements
  23            Inability to demonstrate 2% annual ongoing       2             2               4                   L                 Data collection system is now in place and will be                                   DCS&N                      Sep-06               L             Sep-06             Continually reviewed operational           Y
                increase in Breast Feeding rates                                                                                     supported by the introdution of the West Midlande                                                                                                                     risks
                                                                                                                                     Personal Child Health Record.

  24            Absence of named clinical lead for PCT           2             2              4                    L                 Requirement under the Laming Enquiry. County                                         DCS&N                      Sep-06               L             Sep-06             As above                                   Y
                                                                                                                                     designated doctor currently providing essential named
                                                                                                                                     doctor services and Dr Andy Mills (WF lead Consultant)
                                                                                                                                     is currently putting forward new proposals to reorganise
                                                                                                                                     the paediatric team to ensure that this role is
                                                                                                                                     appropriately covered.

  25            Inability to reach target immunisation rates     3             2              6                M                     MMR uptake inconsistent across GP practices. Overall                                 DCS&N                      Oct-06             M               Sep-06             As above
                                                                                                                                     targets not being met. Working party, which is a sub
                                                                                                                                     group of the County Immunisation Review Group, has
                                                                                                                                     been formed to investigate ways of increasing uptake
                                                                                                                                     and is developing an Action Plan and MW and MM will
                                                                                                                                     attend the Practice Managers Group to discuss
                                                                                                                                     associated issues.
                                                                                                                                                                                                                                                                                                                                                      Y
  26            Services diminishing. Services for children      3             2              6                M                     CAMHs consultant has now been appointed. A meeting                                   DCS&N                      Sep-06             M               Sep-06             As above
                with LD/LD and MH problems will not meet                                                                             is taking place during July 2006 to discuss care
                access or comprehensive CAMHs targets.                                                                               pathways for services for children with LD, following the
                                                                                                                                     establishment of which, resource issues will be
                                                                                                                                     addressed.

  27            OT staff fail to meet demand to see              3             2              6                M                     Jenni Stephens is meeting with the Local Authority                                   DCS&N                      Dec-06             M                                  As above
                children, many of who have complex health                                                                            Children's Services lead to develop assessment
                needs, within a realistic time frame.                                                                                processes.




2 of 4                                                                                                                                                                                                                                                                                                                                        4/17/2010
DRAFT BOARD REPORT                                                                                                                                            PCT RISK REGISTER
                                                                                                                                                                  JULY 2006




                                    Summary description of




                                                                                                                                                                                                                            implementing the plan?
                                                                                                                                                                                                                             Who is responsible for
                                                                                                                Likely impact to PCT




                                                                                                                                                                                                    Anticipated resource




                                                                                                                                                                                                                                                                                                                                                 Is this the progress
                                                                                                                                                                                                                                                      Expected date of
                                                                                             Risk score (LxC)




                                                                                                                                                                 Summary of risk




                                                                                                                                                                                                                                                                                                                            Progress report
                                                                              Consequences




                                                                                                                                                                                                                                                                                           Date of review
                                                                                                                                                                                                       implication (£)




                                                                                                                                                                                                                                                                         Residual Risk
  Risk Number




                                                                                                                                                                                                                                                                                                                                                     acceptable?
                                                                                                                                                                                                                                                        completion
                                                                 Likelihood




                                                                                                                                                                   treatment
                                            risk

Objective 6 - Continue Clinical, Staff and Patient Focus
    1           All other locations in which the                   3            3               9                  H                   Being addressed through replacement building                                         DPH                                            L             Sep-06             Ongoing risk                               Y
                decontamination of re-usable medical                                                                                   protocols but remains as a risk under current
                devices is carried out are dedicated for                                                                               arrangements as a separate decontamination room is
                                                                                                                                       not allways available - remains a low residual risk
                the purpose and appropriately
                designed, maintained and controlled
  12            Out Of Hours system integrity                      3            3               9                  H                   Action Plan submitted and endorsed at the March 2006                                DCS&N                      Jul-06               L             Sep-06             Mostly resolved with minor                 N
                                                                                                                                       PEC and Audit Committee meetings. Final issues,                                                                                                                      actions awaiting final resolution
                                                                                                                                       reviewed at the May 2006 Audit Committee, are to be
                                                                                                                                       followed up at its July meeting.

  14            Lack of retention of key staff during              3            4            12                    H                   The importance has been included within the PCT's                                   CE/DPH                     Oct-06              H              Sep-06                                                        Y
                organisational change                                                                                                  response to 'Commissioning a Patient -led NHS'
                                                                                                                                       provided to David Nicholson within the CE's letter dated
                                                                                                                                       20th March 2006. The lack of clear national HR
                                                                                                                                       guidance has not helped in facilitating a solution to this
                                                                                                                                       issue but the reconfiguration workstreams are
                                                                                                                                       producing interim structures to ensure business
                                                                                                                                       continuity.

  15            NICE technologies fail to be adopted within        2            3               6                M                     Processes developed for drug and more recently non-                                  DPH                       Aug-06               L
                the PCT                                                                                                                drug NICE technologies, in conjunction with Clinical
                                                                                                                                       Governance and these are currently being
                                                                                                                                       comprehensively tested.

  22            Failure to make the PCT Board aware of             1            3               3                    L                 Processes are in place for reviewing and dealing with                                DPH                       Oct-06               L             Sep-06
                issues associated with poorly performing                                                                               poor performance issues and appropriate details will be
                doctors, dentists, pharmacists and                                                                                     included within the Director of Public Health's report to
                opticians                                                                                                              the Board




Objective 7 - Maintain Personal, Team Building and Organisational Development
    4           Continuous review of resources for                 2             2               4                   L                 In the context of the requirement placed on the county                                    DF                   Sep-06             M               Sep-06             Removed - Agreed at the Risk               Y
                organisational development                                                                                             to deliver significant managegement cost savings as                                                                                                                  Management Committee 25th
                                                                                                                                       part of the proposed creation of a single Worcestershire                                                                                                             July 2006 that this risk was now
                                                                                                                                       PCT, there is a genuine risk regarding management                                                                                                                    covered by rik number 14 within
                                                                                                                                       capacity and the Reconfiguration Steering Group has
                                                                                                                                                                                                                                                                                                            the Assurance Framework
                                                                                                                                       initiated a piece of work to review the extent of this.


  21            Failure to provide statutory training to staff     1            3               3                    L                 Developed thorough the Agenda for Change framework                                  DCS&N                      Oct-06               L             Sep-06             Statutory Training maintained              Y
                                                                                                                                       including KSF's and PDP processes for all                                                                                                                            despite financial constraints
                                                                                                                                       posts.Induction and course attendance records are
                                                                                                                                       currently being reviewed




3 of 4                                                                                                                                                                                                                                                                                                                                          4/17/2010
DRAFT BOARD REPORT                                                                                                                                        PCT RISK REGISTER
                                                                                                                                                              JULY 2006




                                  Summary description of




                                                                                                                                                                                                                        implementing the plan?
                                                                                                                                                                                                                         Who is responsible for
                                                                                                            Likely impact to PCT




                                                                                                                                                                                                Anticipated resource




                                                                                                                                                                                                                                                                                                                                             Is this the progress
                                                                                                                                                                                                                                                  Expected date of
                                                                                         Risk score (LxC)




                                                                                                                                                             Summary of risk




                                                                                                                                                                                                                                                                                                                       Progress report
                                                                          Consequences




                                                                                                                                                                                                                                                                                       Date of review
                                                                                                                                                                                                   implication (£)




                                                                                                                                                                                                                                                                     Residual Risk
  Risk Number




                                                                                                                                                                                                                                                                                                                                                 acceptable?
                                                                                                                                                                                                                                                    completion
                                                             Likelihood




                                                                                                                                                               treatment
                                          risk

Objective 8 - Continue Accountability and Governance and Public Confidence role
    5           Organisational training & development          2             2               4                   L                 In the context of the requirement placed on the county                                    DF                   Sep-06             M               Sep-06                                                         Y
                plans Development of training strategies                                                                           to deliver significant managegement cost savings as
                                                                                                                                   part of the proposed creation of a single Worcestershire
                                                                                                                                   PCT, there is a genuine risk regarding management
                                                                                                                                   capacity and the Reconfiguration Steering Group has
                                                                                                                                   initiated a piece of work to review the extent of this.


    7           No written agreements are obtained             1             2               2                   L                 Agreement drafted between the lead RM&G PCT and                                      DPH                       Aug-06               L             Sep-06             Aiming to report to the August 06           Y
                                                                                                                                   Warwick University. Documentation prepared for                                                                                                                       PCT Board
                                                                                                                                   Warwickshire and copy awaited for drafting agreement
                                                                                                                                   for potential adoption by SW PCT.

  16            Treatment protocols for abusive patients       2            3               6               M                      Zero tollerance approach has been adopted within the                                DCS&N                      Sep-06             M               Sep-06                                                        Y
                                                                                                                                   PCT and countywide policies are being drawn up by the
                                                                                                                                   R&B SMS specialist for adoption by the successor PCT


  17            Fail to comply with DDA and RE legislation     2            3               6               M                      All PCT policies are currently being reviewed in line with                           DCS                       Sep-06               L             Sep-06                                                        Y
                                                                                                                                   diversity and Race Equality and DDA principles.
                                                                                                                                   Ethnicity details are now incorporated into PALS and
                                                                                                                                   Complaints protocols for adoption by the successor
                                                                                                                                   organisation.

  20            Committee responsibilities may overlap or      2            2               4                    L                 This issue is now being addressed within a PCT                                      DCS/DPH                    Sep-06             M               Sep-06                                                        Y
                exclude essential areas                                                                                            Reconfiguration Working Group at which TD represents
                                                                                                                                   the PCT. Update was provided to the July PEC/Board
                                                                                                                                   Seminar




4 of 4                                                                                                                                                                                                                                                                                                                                      4/17/2010
                                                                                                                                                                                                                                                                                                               PCT Risk Register September 2005   APPENDIX 1




                                       description of risk




                                                                                                                                                                                                  implementing the



                                                                                                                                                                                                                     Expected date of
                                                                                               Risk score (LxC)




                                                                                                                                                      Summary of risk
                                                                                                                  Likely impact to




                                                                                                                                                                                                                                                                                    Progress report
                                                                                Consequences




                                                                                                                                                                                                   responsible for




                                                                                                                                                                                                                                                          Date of review
                                                                                                                                                                                implication (£)




                                                                                                                                                                                                                                        Residual Risk
  Risk Number




                                                                                                                                                                                                                                                                                                      acceptable?
                                                                                                                                                                                  Anticipated




                                                                                                                                                                                                                       completion
                                                                   Likelihood




                                                                                                                                                                                                                                                                                                       Is this the
                                          Summary




                                                                                                                                                        treatment




                                                                                                                                                                                   resource




                                                                                                                                                                                                                                                                                                        progress
                                                                                                                                                                                                       Who is


                                                                                                                                                                                                       plan?
                                                                                                                        PCT
    1                                         2                      3            4               5                     6                                  7                          8                  9               10             11               12                         13                    14
Objective 1 - Maintain Strategic Direction
    8           Fail to achieve recurrent financial balance          3            5            15                      E             Minor surplus received in                                    DF/ADofC           Sep-06               E             Sep-06             Removed and                    Y
                                                                                                                                     2005/06. Board are routinelly                                                                                                         incorporated into
                                                                                                                                     advised on progress through the                                                                                                       risk number 18
                                                                                                                                     reports of the Directors of Finance
                                                                                                                                     and Commissioning

Objective 2 - Achieve all performance targets identified by the SHA and DoH as included within the LDP, including local targets
    9           Fail to achieve key targets                          4            4            16                      E             Data analysis completed and issues                               DPH            Sep-06               E             Sep-06             Processes                      Y
                                                                                                                                     have been taken forward across the                                                                                                    strengthened to
                                                                                                                                     county with some external support,                                                                                                    reduce emergency
                                                                                                                                     with the aim of achieving certainty and
                                                                                                                                                                                                                                                                           admissions
                                                                                                                                     an understanding of financial risks.
                                                                                                                                     Work is ongoing with the WAT on a                                                                                                     including pooling
                                                                                                                                     countywide basis to investigate a                                                                                                     resources with
                                                                                                                                     variety of demand management                                                                                                          other
                                                                                                                                     schemes.                                                                                                                              Worcestershire
                                                                                                                                                                                                                                                                           PCTs
  10            Fail to implement PBC                                2            3               6                    M             The four criteria for universal coverage                       ADofC            Dec-06              L              Sep-06             Strategy developed             Y
                                                                                                                                     by December have now all been                                                                                                         for universal
                                                                                                                                     developed by the PCT. These are                                                                                                       practice based
                                                                                                                                     specifically - budgets all issued to
                                                                                                                                                                                                                                                                           commissioning
                                                                                                                                     practices, monthly activity and spend
                                                                                                                                     details are provided to all practices,
                                                                                                                                     clinical governance issues have been
                                                                                                                                     addressed with provider accreditation
                                                                                                                                     process and practices have been
                                                                                                                                     made aware of the processes for
                                                                                                                                     offerring directed enhanced services.



  11            Staff do not have access to IT systems               3            3               9                    H             Issues continue to be progressed with                             FD            Sep-06             M               Sep-06             Ongoing rapport                Y
                                                                                                                                     the Director of ICT Services at the                                                                                                   with Director of IT
                                                                                                                                     WHAT and discussed with PCT NEDs'                                                                                                     at WAT
                                                                                                                                     and at the May 06 PEC/Board
                                                                                                                                     Seminar.
  13            Non compliance with PEAT standards                   3            3               9                    H             Acceptable ratings have been provided                        DCS&N/FD           Sep-06             M               Sep-06             Consideration is               Y
                                                                                                                                     for 2005/06 and funds identified within                                                                                               given to PEAT
                                                                                                                                     the capital programme. Specific plans                                                                                                 requirements within
                                                                                                                                     to be agreed following a decision on
                                                                                                                                                                                                                                                                           service
                                                                                                                                     future use of Breedon ward.
                                                                                                                                                                                                                                                                           reconfigurations


Objective 3 - Maintain Financial Management
  18            Failure to achieve key financial targets in a        3            2              6                     M             Being taken through the PCT                                   FD/DCS            Sep-06             M               Sep-06                                            Y
                planned way                                                                                                          Reconfiguration Working Groups and
                                                                                                                                     collaborative working exists to develop
                                                                                                                                     robust countywide SLA's.


Objective 4 - Maintain Operational Development and Delivery
    2           Documented management programme                      2            2              4                      L            Environmental Policy developed,                                  DPH            Sep-06              L              Sep-06                                            Y
                                                                                                                                     reviewed by H&S Committee and to be
                                                                                                                                     agreed by the Clinical Governance
                                                                                                                                     Group, consitantly on a countywide
                                                                                                                                     basis for adoption by the successor
                                                                                                                                     PCT.
    3           Develop indicators                                   2            2              4                      L            Indicators to be developed following                             DPH            Dec-06              L              Sep-06                                            Y
                                                                                                                                     ratification of Policy
    6           Develop business continuity plans to ensure core     3            2              6                     M             Various BCPs now developed and a                             DPH/DCS            Sep-06              L              Sep-06             Current status                 Y
                systems can be retained in the event of system                                                                       process for development of a full PCT                                                                                                 report to be
                failure                                                                                                              BCP, in conjunction with countywide                                                                                                   included within an
                                                                                                                                     PCTs continues through the
                                                                                                                                                                                                                                                                           Annual Report to be
                                                                                                                                     Emergency Planning Officer
                                                                                                                                                                                                                                                                           provided to the
                                                                                                                                                                                                                                                                           September 2006
                                                                                                                                                                                                                                                                           PCT Board
  19            Emergency planning                                   2            3              6                     M             The PCT has liaised with key partner                             DPH            Sep-06             M               Sep-06             As above                       Y
                                                                                                                                     agencies in all aspects of emergency
                                                                                                                                     planning and a formal exercise
                                                                                                                                     programme had been completed. An
                                                                                                                                     Annual Report will be completed for
                                                                                                                                     2005/06 and plans updated.



Objective 5 - Maintain local Service and Performance Agreements
  23            Inability to demonstrate 2% annual ongoing           2            2               4                     L            Data collection system is now in place                        DCS&N             Sep-06              L              Sep-06             Continually                    Y
                increase in Breast Feeding rates                                                                                     and will be supported by the                                                                                                          reviewed
                                                                                                                                     introdution of the West Midlande                                                                                                      operational risks
                                                                                                                                     Personal Child Health Record.
  24            Absence of named clinical lead for PCT               2            2              4                      L            Requirement under the Laming                                  DCS&N             Sep-06              L              Sep-06             As above                       Y
                                                                                                                                     Enquiry. County designated doctor
                                                                                                                                     currently providing essential named
                                                                                                                                     doctor services and Dr Andy Mills (WF
                                                                                                                                     lead Consultant) is currently putting
                                                                                                                                     forward new proposals to reorganise
                                                                                                                                     the paediatric team to ensure that this
                                                                                                                                     role is appropriately covered.


  25            Inability to reach target immunisation rates         3            2              6                     M             MMR uptake inconsistent across GP                             DCS&N             Oct-06             M               Sep-06             As above
                                                                                                                                     practices. Overall targets not being
                                                                                                                                     met. Working party, which is a sub
                                                                                                                                     group of the County Immunisation
                                                                                                                                     Review Group, has been formed to
                                                                                                                                     investigate ways of increasing uptake
                                                                                                                                     and is developing an Action Plan and
                                                                                                                                     MW and MM will attend the Practice
                                                                                                                                     Managers Group to discuss
                                                                                                                                     associated issues.
                                                                                                                                                                                                                                                                                                          Y
  26            Services diminishing. Services for children with     3            2              6                     M             CAMHs consultant has now been                                 DCS&N             Sep-06             M               Sep-06             As above
                LD/LD and MH problems will not meet access or                                                                        appointed. A meeting is taking place
                comprehensive CAMHs targets.                                                                                         during July 2006 to discuss care
                                                                                                                                     pathways for services for children with
                                                                                                                                     LD, following the establishment of
                                                                                                                                     which, resource issues will be
                                                                                                                                     addressed.




5 of 2                                                                                                                                                                                                                                                                                                                                              4/17/2010
                                                                                                                                                                                         PCT Risk Register September 2005   APPENDIX 1




  27     OT staff fail to meet demand to see children,          3   2   6    M   Jenni Stephens is meeting with the          DCS&N     Dec-06   M            As above
         many of who have complex health needs, within a                         Local Authority Children's Services
         realistic time frame.                                                   lead to develop assessment
                                                                                 processes.


Objective 6 - Continue Clinical, Staff and Patient Focus
  1      All other locations in which the                       3   3   9    H   Being addressed through replacement          DPH               L   Sep-06   Ongoing risk            Y
         decontamination of re-usable medical                                    building protocols but remains as a
         devices is carried out are dedicated for the                            risk under current arrangements as a
                                                                                 separate decontamination room is not
         purpose and appropriately designed,
                                                                                 allways available - remains a low
         maintained and controlled                                               residual risk


  12     Out Of Hours system integrity                          3   3   9    H   Action Plan submitted and endorsed at       DCS&N     Jul-06   L   Sep-06   Mostly resolved         N
                                                                                 the March 2006 PEC and Audit                                                with minor actions
                                                                                 Committee meetings. Final issues,                                           awaiting final
                                                                                 reviewed at the May 2006 Audit
                                                                                                                                                             resolution but
                                                                                 Committee, are to be followed up at its
                                                                                 July meeting.                                                               inflated to Medium
                                                                                                                                                             residual risk at July
                                                                                                                                                             RMC because of
                                                                                                                                                             SLA issue.
  14     Lack of retention of key staff during organisational   3   4   12   H   The importance has been included            CE/DPH    Oct-06   H   Sep-06                           Y
         change                                                                  within the PCT's response to
                                                                                 'Commissioning a Patient -led NHS'
                                                                                 provided to David Nicholson within the
                                                                                 CE's letter dated 20th March 2006.
                                                                                 The lack of clear national HR guidance
                                                                                 has not helped in facilitating a solution
                                                                                 to this issue but the reconfiguration
                                                                                 workstreams are producing interim
                                                                                 structures to ensure business
                                                                                 continuity.


  15     NICE technologies fail to be adopted within the        2   3   6    M   Processes developed for drug and             DPH      Aug-06   L            Removed as
         PCT                                                                     more recently non-drug NICE                                                 agreed at the
                                                                                 technologies, in conjunction with                                           13.7.06 Clinical
                                                                                 Clinical Governance and these are
                                                                                                                                                             Governance
                                                                                 currently being comprehensively
                                                                                 tested.                                                                     Strategy Group -
                                                                                                                                                             this area is now
                                                                                                                                                             marked as
                                                                                                                                                             compliant under the
                                                                                                                                                             SfBH declaration

  22     Failure to make the PCT Board aware of issues          1   3   3    L   Processes are in place for reviewing         DPH      Oct-06   L   Sep-06   Risk reviewed at
         associated with poorly performing doctors,                              and dealing with poor performance                                           the July 2006
         dentists, pharmacists and opticians                                     issues and appropriate details will be                                      Clinical
                                                                                 included within the Director of Public
                                                                                                                                                             Governance
                                                                                 Health's report to the Board
                                                                                                                                                             Strategy Group and
                                                                                                                                                             deemed to be the
                                                                                                                                                             remit of the Medical
                                                                                                                                                             Director

Objective 7 - Maintain Personal, Team Building and Organisational Development
  4      Continuous review of resources for organisational      2   2   4    L   In the context of the requirement             DF      Sep-06   M   Sep-06   Removed - Agreed        Y
         development                                                             placed on the county to deliver                                             at the Risk
                                                                                 significant managegement cost                                               Management
                                                                                 savings as part of the proposed
                                                                                                                                                             Committee 25th
                                                                                 creation of a single Worcestershire
                                                                                 PCT, there is a genuine risk regarding                                      July 2006 that this
                                                                                 management capacity and the                                                 risk was now
                                                                                 Reconfiguration Steering Group has                                          covered by risk
                                                                                 initiated a piece of work to review the                                     number 14 within
                                                                                 extent of this.                                                             the Assurance
                                                                                                                                                             Framework
  21     Failure to provide statutory training to staff         1   3   3    L   Developed thorough the Agenda for           DCS&N     Oct-06   L   Sep-06   Statutory Training      Y
                                                                                 Change framework including KSF's                                            maintained despite
                                                                                 and PDP processes for all                                                   financial constraints
                                                                                 posts.Induction and course attendance
                                                                                 records are currently being reviewed



Objective 8 - Continue Accountability and Governance and Public Confidence role
  5      Organisational training & development plans            2   2   4    L   In the context of the requirement             DF      Sep-06   M   Sep-06                           Y
         Development of training strategies                                      placed on the county to deliver
                                                                                 significant managegement cost
                                                                                 savings as part of the proposed
                                                                                 creation of a single Worcestershire
                                                                                 PCT, there is a genuine risk regarding
                                                                                 management capacity and the
                                                                                 Reconfiguration Steering Group has
                                                                                 initiated a piece of work to review the
                                                                                 extent of this.


  7      No written agreements are obtained                     1   2   2    L   Agreement drafted between the lead           DPH      Aug-06   L   Sep-06   Aiming to report to     Y
                                                                                 RM&G PCT and Warwick University.                                            the August 06 PCT
                                                                                 Documentation prepared for                                                  Board
                                                                                 Warwickshire and copy awaited for
                                                                                 drafting agreement for potential
                                                                                 adoption by SW PCT.


  16     Treatment protocols for abusive patients               2   3   6    M   Zero tollerance approach has been           DCS&N     Sep-06   M   Sep-06   Downgraded to Low       Y
                                                                                 adopted within the PCT and                                                  following
                                                                                 countywide policies are being drawn                                         discussions at the
                                                                                 up by the R&B SMS specialist for
                                                                                                                                                             July RMC
                                                                                 adoption by the successor PCT

  17     Fail to comply with DDA and RE legislation             2   3   6    M   All PCT policies are currently being         DCS      Sep-06   L   Sep-06                           Y
                                                                                 reviewed in line with diversity and
                                                                                 Race Equality and DDA principles.
                                                                                 Ethnicity details are now incorporated
                                                                                 into PALS and Complaints protocols
                                                                                 for adoption by the successor
                                                                                 organisation.
  20     Committee responsibilities may overlap or              2   2   4    L   This issue is now being addressed           DCS/DPH   Sep-06   M   Sep-06                           Y
         exclude essential areas                                                 within a PCT Reconfiguration Working
                                                                                 Group at which TD represents the
                                                                                 PCT. Update was provided to the July
                                                                                 PEC/Board Seminar




6 of 2                                                                                                                                                                                                                        4/17/2010
                                                                                                                  WORCESTERSHIRE PCT INTERIM RISK REGISTER OCTOBER 2006




                                   description of risk




                                                                                                                                                                                                      implementing the



                                                                                                                                                                                                                         Expected date of
                                                                                         Risk score (LxC)




                                                                                                                                                      Summary of risk




                                                                                                                                                                                                                                                                                            Progress report
                                                                                                            Likely impact to
                                                                          Consequences




                                                                                                                                                                                                       responsible for




                                                                                                                                                                                                                                                              Date of review
                                                                                                                                                                                    implication (£)




                                                                                                                                                                                                                                            Residual Risk
  Risk Number




                                                                                                                                                                                                                                                                                                               acceptable?
                                                                                                                                                                                      Anticipated




                                                                                                                                                                                                                           completion
                                                             Likelihood




                                                                                                                                                                                                                                                                                                                Is this the
                                      Summary




                                                                                                                                                        treatment




                                                                                                                                                                                       resource




                                                                                                                                                                                                                                                                                                                 progress
                                                                                                                                                                                                           Who is


                                                                                                                                                                                                           plan?
                                                                                                                  PCT
    1                                     2                    3            4               5                     6                                        7                              8                  9               10             11               12                             13                     14
Objective 1 - Maintain Strategic Direction

Objective 2 - Achieve all performance targets identified by the SHA and DoH as included within the LDP, including local targets
    9           Audit Letter 2004/05 - Fail to achieve key     4            4            16                      E             Data analysis completed and issues have been                               DPH            Sep-06               E             Sep-06             Processes strengthened to           Y
                targets                                                                                                        taken forward across the county with some                                                                                                       reduce emergency
                                                                                                                               external support, with the aim of achieving                                                                                                     admissions including pooling
                                                                                                                               certainty and an understanding of financial risks.                                                                                              resources with other
                                                                                                                               Work is ongoing with the WAT on a countywide                                                                                                    Worcestershire PCTs
                                                                                                                               basis to investigate a variety of demand
                                                                                                                               management schemes.

  10            Audit Letter 2004/05 - Fail to implement       2            3               6                    M             The four criteria for universal coverage by                               ADofC           Dec-06               L             Sep-06             Strategy developed for              Y
                PBC                                                                                                            December have now all been developed by the                                                                                                     universal practice based
                                                                                                                               PCT. These are specifically - budgets all issued                                                                                                commissioning
                                                                                                                               to practices, monthly activity and spend details
                                                                                                                               are provided to all practices, clinical governance
                                                                                                                               issues have been addressed with provider
                                                                                                                               accreditation process and practices have been
                                                                                                                               made aware of the processes for offerring
                                                                                                                               directed enhanced services.



  11            BAF 1.2.1/SfBH Governance C7(a) - Staff        3            3               9                    H             Issues continue to be progressed with the                                   FD            Sep-06             M               Sep-06             Ongoing rapport with                Y
                do not have access to IT systems                                                                               Director of ICT Services at the WHAT and                                                                                                        Director of IT at WAT
                                                                                                                               discussed with PCT NEDs' and at the May 06
                                                                                                                               PEC/Board Seminar.
  13            BAF 5.14/SfBH Care Environment C20(b)          3            3               9                    H             Acceptable ratings have been provided for                              DCS&N/FD           Sep-06             M               Sep-06             Consideration is given to           Y
                and C21 - Non compliance with PEAT                                                                             2005/06 and funds identified within the capital                                                                                                 PEAT requirements within
                standards                                                                                                      programme. Specific plans to be agreed                                                                                                          service reconfigurations
                                                                                                                               following a decision on future use of Breedon
                                                                                                                               ward.



Objective 3 - Maintain Financial Management
  18            BAF 6.1/ SfBH Governance C7(d) - Failure       3            2              6                     M             Being taken through the PCT Reconfiguration                             FD/DCS            Sep-06             M               Sep-06             Also includes the                   Y
                to achieve key financial targets in a                                                                          Working Groups and collaborative working exists                                                                                                 requirement to plan to return
                planned way                                                                                                    to develop robust countywide SLA's.                                                                                                             the PCT to recurrent
                                                                                                                                                                                                                                                                               financial balance, linked to
                                                                                                                                                                                                                                                                               service redesign




Worcestershire PCT interim risk register
PCT board
October 2006                                                                                                                                                                                                                                                                                                             Page 7 of 12
                                                                WORCESTERSHIRE PCT INTERIM RISK REGISTER OCTOBER 2006


Objective 4 - Maintain Operational Development and Delivery
   2   CA EN Criterion 4 - Documented               2   2   4   L   Environmental Policy developed, reviewed by             DPH      Sep-06   L   Sep-06                                  Y
       management programme                                         H&S Committee and to be agreed by the Clinical
                                                                    Governance Group, consitantly on a countywide
                                                                    basis for adoption by the successor PCT.



   3   CA EN Criterion 8 - Develop indicators       2   2   4   L   Indicators to be developed following ratification of    DPH      Dec-06   L   Sep-06                                  Y
                                                                    Policy

   6   CA IT Criterion 10 - Develop business        3   2   6   M   Various BCPs now developed and a process for           DPH/DCS   Sep-06   L   Sep-06   Current status report to be    Y
       continuity plans to ensure core systems                      development of a full PCT BCP, in conjunction                                          included within an Annual
       can be retained in the event of system                       with countywide PCTs continues through the                                             Report to be provided to the
       failure                                                      Emergency Planning Officer                                                             September 2006 PCT Board


  19   BAF 7.8/ SfBH Public Health C24 -            2   3   6   M   The PCT has liaised with key partner agencies in        DPH      Sep-06   M   Sep-06   As above                       Y
       Emergency planning                                           all aspects of emergency planning and a formal
                                                                    exercise programme had been completed. An
                                                                    Annual Report will be completed for 2005/06 and
                                                                    plans updated.



Objective 5 - Maintain local Service and Performance Agreements
  23   Operational - Inability to demonstrate 2%    2   2   4   L   Data collection system is now in place and will be     DCS&N     Sep-06   L   Sep-06   Continually reviewed           Y
       annual ongoing increase in Breast                            supported by the introdution of the West                                               operational risks
       Feeding rates                                                Midlande Personal Child Health Record.

  24   Operational - Absence of named clinical      2   2   4   L   Requirement under the Laming Enquiry. County           DCS&N     Sep-06   L   Sep-06   As above                       Y
       lead for PCT                                                 designated doctor currently providing essential
                                                                    named doctor services and Dr Andy Mills (WF
                                                                    lead Consultant) is currently putting forward new
                                                                    proposals to reorganise the paediatric team to
                                                                    ensure that this role is appropriately covered.


  25   Operational - Inability to reach target      3   2   6   M   MMR uptake inconsistent across GP practices.           DCS&N     Oct-06   M   Sep-06   As above                       Y
       immunisation rates                                           Overall targets not being met. Working party,
                                                                    which is a sub group of the County Immunisation
                                                                    Review Group, has been formed to investigate
                                                                    ways of increasing uptake and is developing an
                                                                    Action Plan and MW and MM will attend the
                                                                    Practice Managers Group to discuss associated
                                                                    issues.


  26   Operational - Services diminishing.          3   2   6   M   CAMHs consultant has now been appointed. A             DCS&N     Sep-06   M   Sep-06   As above                       Y
       Services for children with LD/LD and MH                      meeting is taking place during July 2006 to
       problems will not meet access or                             discuss care pathways for services for children
       comprehensive CAMHs targets.                                 with LD, following the establishment of which,
                                                                    resource issues will be addressed.

  27   Operational - OT staff fail to meet demand   3   2   6   M   Jenni Stephens is meeting with the Local               DCS&N     Dec-06   M            As above                       Y
       to see children, many of who have                            Authority Children's Services lead to develop
       complex health needs, within a realistic                     assessment processes.
       time frame.




Worcestershire PCT interim risk register
PCT board
October 2006                                                                                                                                                                                  Page 8 of 12
                                                                  WORCESTERSHIRE PCT INTERIM RISK REGISTER OCTOBER 2006


Objective 6 - Continue Clinical, Staff and Patient Focus
   1   CA DE Criterion 14 - All other                3   3   9    H   Being addressed through replacement building         DPH               L   Sep-06   Ongoing risk                    Y
       locations in which the decontamination                         protocols but remains as a risk under current
       of re-usable medical devices is carried                        arrangements as a separate decontamination
                                                                      room is not allways available - remains a low
       out are dedicated for the purpose and
                                                                      residual risk
       appropriately designed, maintained
       and controlled

  12   BAF 4.5 - Out Of Hours system integrity       3   3   9    H   Action Plan submitted and endorsed at the March     DCS&N    Jul-06    M   Sep-06   Mostly resolved with            N
                                                                      2006 PEC and Audit Committee meetings. Final                                        minor actions awaiting
                                                                      issues, reviewed at the May 2006 Audit                                              final resolution but inflated
                                                                      Committee, are to be followed up at its July
                                                                                                                                                          to Medium residual risk at
                                                                      meeting.
                                                                                                                                                          July RMC because of SLA
                                                                                                                                                          issue.

  14   BAF 8.1 - Lack of retention of key staff      3   4   12   H   The importance has been included within the         CE/DPH   Oct-06    H   Sep-06                                   Y
       during organisational change                                   PCT's response to 'Commissioning a Patient -led
                                                                      NHS' provided to David Nicholson within the CE's
                                                                      letter dated 20th March 2006. The lack of clear
                                                                      national HR guidance has not helped in
                                                                      facilitating a solution to this issue but the
                                                                      reconfiguration workstreams are producing
                                                                      interim structures to ensure business continuity.



  22   BAF 7.7.4 - Failure to make the PCT           1   3   3    L   Processes are in place for reviewing and dealing     DPH     Oct-06    L   Sep-06   Risk reviewed at the July       Y
       Board aware of issues associated with                          with poor performance issues and appropriate                                        2006 Clinical Governance
       poorly performing doctors, dentists,                           details will be included within the Director of                                     Strategy Group and
       pharmacists and opticians                                      Public Health's report to the Board
                                                                                                                                                          deemed to be the remit of
                                                                                                                                                          the Medical Director

  28   Operational - Fail to adequately respond to   2   3   6    M   Addressed through Redditch and Bromsgrove            DPH     Dec-06    M     Oct-06 New Risk July 06 - Caron        Y
       TB cases/outbreak on a countywide basis                        PCT as lead commissioners for tuberculotis                                          Grainger to initiate
                                                                      services                                                                            discussions between HPA,
                                                                                                                                                          commissioners and Primary
                                                                                                                                                          and secondary Care
                                                                                                                                                          providers

  29   Operational - Likelyhood of patient with      3   2   6    M   Diagnosis and transfer of CDAD patients and the      DPH     Ongoing   M   Dec-06   Audit of practice and           Y
       Clostridium difficile associated diarrhoea                     associated care, treatment and management                                           compliance with policies,
       (CDAD)                                                         within the PCT.                                                                     availability and knowledge
                                                                                                                                                          of evidence based
                                                                                                                                                          guidance, provision of fact
                                                                                                                                                          sheets for General
                                                                                                                                                          Practice, provision of
                                                                                                                                                          patient leaflets, ALERT
                                                                                                                                                          organism surveillance and
                                                                                                                                                          follow up of patients with
                                                                                                                                                          a positive laboratory
                                                                                                                                                          isolate, review of
                                                                                                                                                          commissioning
                                                                                                                                                          procedures in relation to
                                                                                                                                                          diagnosis of CDAD




Worcestershire PCT interim risk register
PCT board
October 2006                                                                                                                                                                                  Page 9 of 12
                                                               WORCESTERSHIRE PCT INTERIM RISK REGISTER OCTOBER 2006


  30   Changes by DH in guidance for               3   1   3   L   Risk of local re-processing not complying        DPH    Ongoing   L            Audit of practice,          Y

       localised decontamination of                                with latest DH guidance                                                        promotion of best
       reusable instruments may render                                                                                                            practice and alternatives
       compliance in some areas                                                                                                                   such as use of central
       problematic.                                                                                                                               service or disposable
                                                                                                                                                  items, provision of
                                                                                                                                                  guidance and advice

Objective 7 - Maintain Personal, Team Building and Organisational Development
  21   BAF 3.2 and 3.11/SfBH C11(b) - Failure to   1   3   3   L   Developed thorough the Agenda for Change        DCS&N   Oct-06    L   Sep-06   Statutory Training          Y
       provide statutory training to staff                         framework including KSF's and PDP processes                                    maintained despite
                                                                   for all posts.Induction and course attendance                                  financial constraints
                                                                   records are currently being reviewed




Worcestershire PCT interim risk register
PCT board
October 2006                                                                                                                                                                      Page 10 of 12
                                                               WORCESTERSHIRE PCT INTERIM RISK REGISTER OCTOBER 2006


Objective 8 - Continue Accountability and Governance and Public Confidence role
   5   CA Governance Criterion 4 -                 2   2   4   L   In the context of the requirement placed on the        DF      Sep-06   M   Sep-06                              Y
       Organisational training & development                       county to deliver significant managegement cost
       plans Development of training strategies                    savings as part of the proposed creation of a
                                                                   single Worcestershire PCT, there is a genuine
                                                                   risk regarding management capacity and the
                                                                   Reconfiguration Steering Group has initiated a
                                                                   piece of work to review the extent of this.



   7   CA Research Governance Criterion 4 - No     1   2   2   L   Agreement drafted between the lead RM&G PCT           DPH      Aug-06   L   Sep-06   Aiming to report to the    Y
       written agreements are obtained                             and Warwick University. Documentation                                                August 06 PCT Board
                                                                   prepared for Warwickshire and copy awaited for
                                                                   drafting agreement for potential adoption by SW
                                                                   PCT.


  16   BAF 5.13.5/SfBH Environment and             2   3   6   M   Zero tollerance approach has been adopted            DCS&N     Sep-06   L   Sep-06   Residual risk downgraded   Y
       Ameneties C20(a) - Treatment protocols                      within the PCT and countywide policies are being                                     to Low following
       for abusive patients                                        drawn up by the R&B SMS specialist for adoption                                      discussions at the July
                                                                   by the successor PCT
                                                                                                                                                        RMC

  17   BAF 7.6/SfBH Accessibility and              2   3   6   M   All PCT policies are currently being reviewed in      DCS      Sep-06   L   Sep-06                              Y
       Responsive Care C17 - Fail to comply with                   line with diversity and Race Equality and DDA
       DDA and RE legislation                                      principles. Ethnicity details are now incorporated
                                                                   into PALS and Complaints protocols for adoption
                                                                   by the successor organisation.

  20   BAF 1.2.6 and 7.2.1 - Committee             2   2   4   L   This issue is now being addressed within a PCT       DCS/DPH   Sep-06   M   Sep-06                              Y
       responsibilities may overlap or exclude                     Reconfiguration Working Group at which TD
       essential areas                                             represents the PCT. Update was provided to the
                                                                   July PEC/Board Seminar



       Key:
       PBC    Pactice Based Commissioning
       BAF    Board Assurance Framework
       SfBH   Standards for Better Health
       CA     Controls Assurance
       EN     Enviromental Management
       DE     Decontamination of re-useable
               Medical Devices




Worcestershire PCT interim risk register
PCT board
October 2006                                                                                                                                                                           Page 11 of 12
                                                                                                                                    WORCESTERSHIRE PCT INITIAL RISK REGISTER DECEMBER 2006




                                                                                                                                                                                                                                                                                                                                                  reference number
                                     description of risk




                                                                                                                                                                                                   implementing the



                                                                                                                                                                                                                       Expected date of




                                                                                                                                                                                                                                                                                                                              Source of risk by
                                                                                              Risk score (LxC)




                                                                                                                                                      Summary of risk
                                                                                                                 Likely impact to




                                                                                                                                                                                                                                                                                        Progress report
                                                                               Consequences




                                                                                                                                                                                                    responsible for




                                                                                                                                                                                                                                                            Date of review
                                                                                                                                                                                 implication (£)




                                                                                                                                                                                                                                          Residual Risk
   Risk Number




                                                                                                                                                                                                                                                                                                          acceptable?
                                                                                                                                                                                   Anticipated




                                                                                                                                                                                                                         completion
                                                                  Likelihood
                                        Summary




                                                                                                                                                                                                                                                                                                           Is this the
                                                                                                                                                        treatment




                                                                                                                                                                                    resource




                                                                                                                                                                                                                                                                                                            progress




                                                                                                                                                                                                                                                                                                                                                       Previous
                                                                                                                                                                                                        Who is


                                                                                                                                                                                                        plan?
                                                                                                                       PCT




                                                                                                                                                                                                                                                                                                                                   PCT
     1                                      2                       3             4               5                    6                                    7                          8                  9                10             11                12                          13                    14                  15                  16

Healthcare Standard Domain 1 - SAFETY patient safety is enhanced by the use of healthcare processes working practices and systematic activities that prevent or reduce the risk of harm to patients
Healthcare standard domain 2 - CLINICAL AND COST EFFECTIVENESS: patients achieve healthcare benefits that meet their individual needs through healthcare decisions and services based on what
assessed research evidence has shown provides effective clinical outcomes
Healthcare standards domain 3 - GOVERNANCE: managerial and clinical leadership and accountability as well as the organisation's culture, systems and working practices ensure that probity, quality
assurance , quality improvement and patient safety are central components of all activities of the healthcare organisation
   G4            Lack of achievement of objectives due to           5            4            20                      E             To ensure that the reorganisation begins         N/A                CE            Sep-06               E              Mar-07             Structures continually            Y           Redditch and              39
                 reorganisation and freezing of managerial                                                                          as quickly as possible within the SHA time                                                                                               progressed and                              Bromsgrove PCT
                 and other non-clinical posts                                                                                       frame                                                                                                                                    objectives developed

   G8            Lack of financial balance in Worcestershire        4             5           20                       E            Monitor agreed arrangements and                  N/A           CE and DF Ongoing                        E             Mar-07  Key risk identified                          Y           Redditch and               20
                 organisations and therefore loss of financial                                                                      implement corrective actions across the                                                                                       within WPCT being                                      Bromsgrove PCT
                 support from SHA                                                                                                   health economy                                                                                                                reviewed at
                                                                                                                                                                                                                                                                  Management Team and
  G11            Audit Letter 2005/6 - Preparations for PCT         4             4           16                       E            Chief Exec and Director of Finance and           N/A                 DF           Ongoing               E             Ongoing Board identified
                                                                                                                                                                                                                                                                  Key risk                                     Y              South
                 Merger Delay in appointing new team.                                                                               Director of Clinical Development                                                                                              within WPCT being                                       Worcestershire
                 Transition Team needs to create a new                                                                              appointed.                                                                                                                    reviewed at                                            PCT/Redditch &
                 WPCT CIP and reduce the risks in the                                                                                                                                                                                                             Management Team and                                      Bromsgrove
                 current CIPs; identify how the 15%                                                                                                                                                                                                               Board                                                  PCT/Wyre Forest
                 management cost saving will be achieved;                                                                                                                                                                                                                                                                     PCT
                 how key targets are to be achieved via a
                 new LDP
Healthcare standards domain 4 - PATIENT FOCUS healthcare is provided in partnership with patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership
with other organisations (especially social care organisations) whose services impact on patient well being

Healthcare standards domain 5 - ACCESSIBLE & RESPONSIVE CARE: patients receive services as promptly as possible, have choice in access to services and treatments, and do not experience unnecessary
delay at any stage of service delivery or the care pathway
 ARC7            Waiting Lists particularly the management of       4             5           20                       E            Ensure included in LDP on an ongoing             N/A              DC&R            Mar-07                E             Mar-07             Recognised as a major             Y         Wyre Forest PCT
                 routine waiting lists in Therapy Services, OT,                                                                     basis.                                                                                                                                   issue to be addressed
                 physio, podiatry, CAMHS, OT and SALT in                                                                                                                                                                                                                     as part of the 2007/08
                 Specialised Childrens Services                                                                                                                                                                                                                              LDP

 ARC8            Lack of beds for young mentally ill children       4             4           16                       E            Patients being managed at home because           N/A               DPS            Mar-07                E             Mar-07             As above                          Y         Wyre Forest PCT
                                                                                                                                    of a lack of NHS and private beds.

Healthcare standards domain 6: CARE ENVIRONMENT AND AMENITIES: care is provided in environments that promote patient and staff well being and respect for patients' needs and preferences in that they
are designed for the effective and safe delivery of treatment, care or a specific function
Healthcare standards domain 7: PUBLIC HEALTH: programmes and services are designed and delivered in collaborate with all relevant organisations and improve the health of the population served and
reduce health inequalities between different population groups and areas




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